Nokea
The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
- A. Remove any mafenide that has been applied.
- B. Immediately notify the health care provider.
- C. Double-check the concentration of mafenide.
- D. Inform the client that this is a normal response.
Correct Answer: D
Rationale: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
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The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.
The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
Which statement by the nurse most accurately explains the pathophysiology of conductive hearing loss?
- A. Sound waves do not travel to the inner ear.
- B. There is a malfunction of inner ear structures.
- C. The auditory nerve does not transmit sound to the brain.
Correct Answer: A
Rationale: Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear.
The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client?
- A. Encourage the client to get the chickenpox immunization.
- B. Do not engage in oral sex if you have a cold sore on the mouth.
- C. Wear nonsterile gloves when cleaning the genital area.
- D. Do not share any type of towel or washcloth with another person.
Correct Answer: B
Rationale: Avoiding oral sex with a cold sore (HSV-1) prevents HSV-2 transmission to genitals. Chickenpox vaccine, gloves, and towels are unrelated.
The nurse is assessing the client using desoximetasone topical cream for an abdominal rash. Which finding should indicate to the nurse that the client is experiencing a known side effect from the medication?
- A. Skin discoloration
- B. Skin thickening
- C. Decreased striae
- D. Increased skin hair
Correct Answer: A
Rationale: The presence of skin discoloration such as purpura and hyperpigmentation should indicate to the nurse that the client has a side effect from using desoximetasone (Topicort). Thinning skin, not thickening, is a side effect. The presence of striae, not a decrease, is a side effect. Folliculitis, not increased skin hair, is a side effect.